Parental presence during invasive pediatric procedures: what does it depend on?

Abstract Objective: family-centered care during invasive procedures has been endorsed by many professional health care organizations. The aim of this study was to evaluate the health professionals’ attitudes towards parental presence during their child’s invasive procedure. Method: pediatric healthcare providers (divided in professional categories and range of ages) from one of the Spain’s largest hospitals were asked to complete a questionnaire and write free-text comments. Results: 227 responded the survey. Most (72%) participants, in their answers, reported that parents are sometimes present during interventions, although there were differences between professional categories in this respect. The procedures in which the parents were present were those considered “less invasive” (96% of cases), while only 4% were present in those considered “more invasive”. The older the professional, the less necessary parental presence was considered. Conclusion: the attitudes towards parental presence during pediatric invasive procedure are influenced by the professional category, the age of the healthcare provider and the invasiveness of the procedure.


Introduction
Until the first half of the 20 th century, children were systematically separated from their parents during hospitalization. The psychoanalysts René Spitz and John Bowlby strongly contributed to our understanding and knowledge of the psycho-affective consequences of this parental deprivation for young infants, defining it as "hospitalism" and proposing the "attachment theory", respectively (1)(2)(3)(4) . These authors initiated the trend from the traditional paternalistic model of medicine towards family-centered care (5) , which involves a greater degree of partnership between the family and health care providers (1,(6)(7)(8) .
Invasive pediatric procedures can be painful and frightening experiences for children and their parents. In the European Charter for hospitalized children (1986), it is established that it is a child's right to be accompanied by their parents throughout the hospitalization process, with parents becoming an active part of hospital life (9) .
In addition, parents' interest in being present when procedures are performed has increased over the years (10) .
Many publications demonstrate the desire of parents to accompany their children during the performance of painful procedures such as venipunctures, placement of venous accesses, urethral catheterization or performing a lumbar puncture and it presence is beneficial for both family members and health care staff (11) . There is significant evidence that the parental presence during invasive procedures can reduce a child's anxiety and pain, while accelerating the recovery process in children and reducing the anxiety of family members (12)(13)(14) . Moreover, different medical and nursing associations have all put forward recommendations or resolutions concerning the presence of family members during invasive procedures and, if necessary during resuscitation in the hospital (15)(16)(17) .
However, some of the healthcare professionals are less willing to allow such parental presence despite it being the child's right. The two main reasons expressed by the care providers in this respect include parental anxiety and the greater nervousness on the part of children. Other reasons are related with the time required to explain the procedure to parents and the healthcare providers' anxiety for the parental presence during the intervention (18) . Some authors suggest undeniable evolution in the professionals' opinions concerning parental presence (19) . In most cases, the attitudes of health professionals are evaluated through questionnaires because of the difficulty involved in analyzing free texts.
The aim of this study was to evaluate the health professionals' attitudes towards parental presence during their child's invasive procedure.

Type of study and localization
This is a cross-sectional study, guided by the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guideline, used to report observational studies (20) . The study was performed by means of an anonymous self-administered questionnaire in a large University hospital in Murcia, Mur, Spain.

Period
The data collection period was between October 3 rd , 2019 and June 30 th , 2020.

Population and selection criteria
The hospital employs 4000 health professionals (

Sample definition
All the workers of pediatric units were invited to the study. In order to avoid bias a minimum sample size base on the total eligible population (n=444) was calculated using the statistical software SAS University Edition. To determine the minimum sample size of responders with statistical relevance, a 75% rate of parental presence with a precision of 5% and a confidence level of 95% was estimated based on previous studies in Spain (23) .
The resulting minimum sample size was 175. The final responders obtained in our study were 227, countersigning the robustness of our results. This sample size was selected after dividing into professional categories and according to pediatric units.
questionnaire was based on a published questionnaire (18) , originally developed in Spanish to access the parental presence during invasive procedures in the perspective of those responsible for Pediatric Emergency Services and active members of Spanish Society of Pediatric Emergencies.
The questionnaire contained sociodemographic information (gender, age), professional category (pediatrician, pediatrician resident, pediatric nurse, pediatric nurse resident and nursing assistant) and pediatric units.
The survey covered variables such as parental presence during invasive pediatric procedures (yes, yes sometimes, no), the type of procedures performed which parents were allowed to be present (eleven invasive procedures could be selected), the reasons for any reluctance to allow parental presence (related to parents, to the child, interruption of the procedure or aggression and claims) and an evaluation of the existence for protocols and specific training regarding parental presence (yes, no). Moreover, a Likert scale were used to determine the frequency of the problems derived from the presence of the parents (never, occasionally, frequently, always). After completing the questionnaire, participants were invited to write free-text comments, motivated by the sentence: "We would appreciate any comment on the subject". Eleven invasive procedures were included in the study and divided according to the degree of invasiveness, into less and more invasive (Figure 1).

Data collection
The workers were invited through the institutional email service. After that, printed questionnaires and informed consent form were sent to each pediatric unit.
As a strategy during data collection, visits were made to all of the units to invite and instruct the professionals to participate in the research.

Data treatment and analysis
The questionnaires received were processed using Microsoft Excel, and statistical analysis was performed using the statistical software SAS University Edition.
The presence/absence of parents during invasive procedures with their children, the age ranges of healthcare professionals (<40, 40-50, >50 years), and the proportion of parents present in "more" or "less" invasive procedures were analyzed using Pearson's χ2 analysis.
A multivariate analysis (Fisher logistic regression) was explored considering presence/absence of parents as dependent variable and professional category and age as independent variables.
The free-text comments in the questionnaires were evaluated by a text analyst program KH coder (24) , which produces a list of words ordered according to their frequencies and interrelationships to analyze and visualize the text content as a co-occurrence network. Frequently co-occurring terms in the visualization are connected by lines/edges: the relative frequency of terms is indicated by the relative size of their node, and the relative frequency of co-occurrence of terms is indicated by the relative thickness of the edge connecting their nodes.

Ethical aspects
This study was carried out in accordance with the ethical standards established by the Helsinki Declaration  In terms of the type of procedures where parents were allowed to be present, the percentages were 96%

Analysis of questionnaires
in the case of "less invasive" and 4% in the case of "more invasive" (p<0.0001).
In regard to any problems derived from parental presence, 61% of the professionals reported occasional problems (n=122), 29% had never had problems (n=58) and 10% said they frequently had problems (n=18).
No differences were found when these results were

Quantitative free-text analysis
Fifty-nine respondents wrote comments in the freetext part of the questionnaire. Analysis of their comments showed that 1435 words were used in a total of 75 sentences. The most frequent words were the verb "be" (101 times), followed by "parent" and "child" (74 and 35 times, respectively), the adverb "not" (35 times), "procedure" (26 times), and the noun "presence" (24 times).
The results of the co-occurrence network of words analysis revealed 11 clusters regarding how the professionals evaluated parental presence during invasive pediatric procedures ( Figure 5). The reported problems related to such presence were: greater nervousness on the part of child (37%, n=83), parent's indisposition (example: dizziness) (35%, n=80), interrupting the procedure (22%, n=49) and others such as aggression or complaints (7%, n=17).
Most professionals thought that parental presence was unnecessary and preferred to perform procedures without them (72% n=164), while 28% (n=53) thought such presence was necessary. The main reasons stated for the reluctance to allow parents to be present were parental anxiety (65%), the belief that the parents are not prepared to stay (41%), the invasiveness of the procedures (39%), reduced physical space (23%), the idea that they would perform less well (20%) and greater nervousness on the part of child (18%). The most important cluster in terms of frequency of the words used and the thickness of it edges was cluster 7 represented in green in Figure 5. This cluster contained the words "be, parent, do, not, procedure, child, presence"

Most of the professionals in group aged
and some examples of sentences using these words are: "Parents should not be present during invasive procedures", "I think it depends a lot on the type of parents and the child, it cannot be generalized" or "I don't think it's good for the child to associate parents with pain in a procedure".
Another important cluster is number 10 (in purple), which matched the words "get" and "nervous" as exemplified by the sentences: "I think that parents should not be present, they get very nervous" or "I do not agree that the parents be present during procedures, they get very nervous".
Cluster 5 (in blue) brought together "prepare", "hurt", "understand" and "more", as in the comments: "Children are more restless (they do not understand that they are hurting them and their parents do not defend them), professionals feel supervised and most families are not prepared". "I think that in some techniques some parents are not prepared to understand what we do".
Another cluster relates to the performance of professionals (number 3, colored light purple in Figure 5) and include words like: "perform", "experience", "become", "cry" and "outside". One example of a sentence included in this cluster is "When a procedure is performed on the child, the parents should not be there because if the child cries, the parents become nervous, it is better to do it without them".

Discussion
In our study, the vast majority of the pediatricians, nurses, and nursing assistants (72%) said that they sometimes perform invasive procedures in children with parental presence. Nineteen percent of them claimed that they never perform invasive procedures with parental presence and 9% affirmed that they always performed procedures in the presence of the parents. There were differences between the different professional categories concerning the answers "never" and "always". Pediatricians performed more procedures with parental presence than pediatric residents (100% and 14%, respectively). Furthermore, previous studies of "more invasive" procedures. Also, other authors have demonstrated that the more invasive the procedures are, the less professionals want to have parents present (48) .
Few problems regarding parental presence during invasive procedures were reported by the respondents.
Most of the providers (90%) mentioned occasional (61%) or no problems (29%) had arisen during a given procedure, coinciding with other study, which found a high level of satisfaction (57%) of the professionals when an invasive procedure is performed in the presence of parents. Furthermore, in the same study, 90% of family members and 76% of professionals believed that it had been beneficial for the child (23) and considered the family as a resource in nursing care (31) . pediatric procedural distress (49) and even the follow-up of the treatment recommendations after discharge (50)(51) .
An active role can be achieved by parents with timely, relevant information and could also help them feel in control of the situation, and relieves their own stress (52)(53) .
Both parents and healthcare providers have a role in reducing the distress and pain that children experience during necessary medical procedures and none of them have to be eliminated in this paramount purpose.
In our study, 65.4% of the 227 professionals did not consider the presence of the parents to be necessary.
Regarding that, an innovative free-text analysis was used for the first time to evaluate the comments on parental presence wrote by healthcare providers, although KH Coder have been used in studies of public health (54)(55) .
This analysis demonstrated the increased understanding of people's attitude to a given topic (54,56) and revealed that the most important cluster (number 7) used words such as "not", "parent", "presence" and "procedure". This analysis is in accordance with the result of the questionnaire in which more than a half of the responders are contrary to the need of parental presence. Similar figures to ours were obtained in an study carried out in the emergency service of a Spanish hospital, in which only 60% of the providers in Europe showed that residents from various specialties more often prefer paternalistic decision making than their supervisors. They suggest that this might be attributed to differences in the degree of professional confidence and their lack of knowledge about shared decision making (25) .

Pediatric residents could show lack of confidence compared
with the skills of more experienced pediatricians. However, a study found little difference between the satisfaction of both groups concerning the presence of parents during an intervention (23) . In our study, we also found differences pediatricians in some countries of Asia (28)(29)(30)(31) . These results could also be explained in our context because, most of the pediatric nurses were unable to get their specialty in pediatric care because the pediatric specialty is relatively young in Spain. However, all other professional categories were able to get it or were undergoing pediatric training.
In regard to the wishes of parents to be present during invasive procedures even in worse-case scenarios such as critically ill children or resuscitation, they want to be there (32)(33)(34)(35) . It has been also reported that families perceive that their presence is helpful to the patient and essential for medical care (36) . They need to feel part of, and be involved in, their child's care and their presence increases their sense of control, helps them to cope with the stressful situation and the satisfaction and relationship with health-care providers (6,(37)(38)(39) . Although evidence for the use physical (e.g., breastfeeding, kangaroo/ maternal holding, nonnutritive sucking, white noise in new-born (38)(39)(40) ), and psychological (e.g., clown therapy, distraction (41-45) ) interventions to manage procedural pain has been widely advocated in the published literature, and is the family the driver of many of them, the implementation in practice sometimes is lacking (46)(47) . In our study, parents were allowed to be present in 96% of "less invasive" interventions, and only in 4% in the case www.eerp.usp.br/rlae 8 Rev. Latino-Am. Enfermagem 2023;31:e3828.
approved of the presence of the parent during less invasive procedures, and only 10.8% would encourages the family's presence during resuscitation (57) . The views of pediatric nurses concerning parental presence during painful procedures, evaluated in a Turkish study, stated that 56.3% of the nurses thought that parents should not be present during invasive procedures (29) . However, higher figures of parental presence during anesthesia induction (86.9%) were obtained when nurse anesthetist were asked in a nationwide survey in Sweden (31) .
The present study notes that the reasons given for any reluctance to allow parental presence are mainly parent-related, including parental anxiety (65%), belief that parents are not prepared to stay (41%), the invasiveness itself of the procedure (39%), reduced physical space (23%), poorer care performance (20%) and greater nervousness on the part of child (18%). In the case of parental anxiety, these results were reinforced in the free text analysis, where cluster number 10 associated words like "get" and "nervous". The belief that parents are not prepared was represented in the free text comments by cluster number 5 with words like: "prepare" and "understand". Somehow the clusters 10 and 5 can be associated with the theme "Not prepared for the experience" that was reported by some healthcare providers in face-to-face, in-depth, semistructured individual interviews in a qualitative study in South Africa (58) . Otherwise, the invasiveness of the procedure and poorer provider performance can be seen in cluster number 3 that matched words like "perform", "experience", "become", cry" and "outside" and could fits with the theme "A traumatic experience" in the same study" (58) .
Parental anxiety was also given for reluctance to allow parental presence in another study carried out in an emergency pediatric service (86% of the respondents), being similar to our results. By contrast, other explanations were more frequent: fear of poorer staff performance (77%), belief that parents are not prepared to stay (76%), the invasiveness of the procedure (70%), and increase child anxiety (39%) (18) . Maintaining self-control during their child's procedure was important for parents and represented a significant source of stress. For some parents, emotions (e.g., a fear of needles) interfered with their ability to be present during a procedure, making them feel guilty or that they were not fulfilling their parental role.
In some cases could be the "important others" (families of parents or friends) the ones who help and support the pediatric invasive procedure (59) . Thus, parental preference varies, that´s why an open line of communication with healthcare providers and acceptance of parents' views can support participation and improve child safety (60) .
There is a vast quantity of scientific information concerning the benefits of parental presence during invasive pediatric procedures (12)(13)(14) , based on which findings some hospital have proposed the figure of family presence facilitator. This person would be charged with giving proper explanations of the procedure to parents, which would be easier and faster manner of involving them in their child's care (61) . The family presence facilitator would work with both parents and health professionals. We are of the opinion that such a post would be worth creating in our and other hospitals to reduce any reluctance to accepting the presence of a parent.
In reference to the ages of professionals and their views concerning necessity of parent presence, our study found that the older the care provider the less parental However, such differences were not found in a large Asian study concerning professional experience or age and the preference for parental presence. In the study (48) more than 90% of the pediatricians and nurses preferred to perform procedures without the parent's presence.
Parents want to be present during invasive procedures and they recommend being present to support increased coping for their children (37) . However, parents may suffer high anxiety levels in the face of invasive procedures, which could perhaps be reduced if suitable information about what is going happen in a particular procedure.
Without such information a parent´s anxiety could have a negative effect on their children (64) . Despite that, the fact that 65% of the healthcare providers in our study did not consider the presence of the parents to be necessary, we found a high percentage of demand for written protocols to be adhered to during professional service (82% of professionals) and trainings (75%) on parental presence showing that they need professional tools and scientific support to fully implement family centered care within their services. Without a clear understanding of family care management, the concept is at risk of being relegated to a vague colloquial expression (65) . Moreover it has been seen that permitting a parent's presence and changes in traditional views might occur if the professionals had protocols and were properly trained (36) .  Palomares-González L, Hernández-Caravaca I, Gómez-García CI, Sánchez-Solís de Querol M.
but also decrease children's pain, stress and negative behavior in general during invasive procedures (14) . This would also improve the professional comfort during procedures and well-being of the entire family (61,66) . To successfully implement family-centered care, a shift in healthcare provider caregiving practices is necessary to promote mutual respect, collaboration, and support for parents. To create such protocols, a multidisciplinary team is required to identify, coordinate and address shared Another limitation could be the lack of a pure qualitative study. Future research with individual interviews or even through focal groups may be a future path for a better understanding of the object and scenario studied.
The contribution of this study allows us to know the perspectives of healthcare professionals about a very important subject. In most of the countries, where familycentered care in more implemented, exist internal policies to be follow by the professionals that allow parents to be present in all procedures. Thus, in these cases the attitude of practitioner is less important. However, in our context, parental presence is determined by the professional´s attitude. According to our study findings, there is a demand for written protocols or guidelines and specific trainings. This could speed up the acceptance of parental presence during invasive procedures. Moreover, the main reason stated for the reluctance to allow parents to be present were parental anxiety. This can be management with timely and relevant information to make parental interventions an important tool for professionals (67) and not a problem to increase child´s well-being and safety during invasive procedures.

Conclusion
The results showed that the attitudes towards parental presence during invasive pediatric procedures are influenced by the professional category, age and the degree of invasiveness of the procedure. Moreover, more than half of the respondents did not perceive the presence of a parent as being necessary when invasive procedures are being performed. The rare problems reported when parents were present during invasive procedures were mainly related with greater nervousness on the part child, the parent's indisposition, and interruption of the procedure. The findings show that there is a widely felt demand for written protocols and specific training in the different medical units to clarify how best to include parents in child´s care during invasive procedures.

Conflict of interest
None of the authors has any conflict of interest to declare.